1
CMS and ONC: Enabling Data Interoperability
Across the Continuum
Session 101, February 13, 2019
Elizabeth Palena Hall, ONC; Beth Connor, CMS
Michelle Dougherty, RTI International; Dave Hill, MITRE
2
Conflict of Interest
Elizabeth Palena Hall, ONC
Has no real or apparent conflicts of interest to report.
Beth Connor, CMS
Has no real or apparent conflicts of interest to report.
Michelle Dougherty, RTI International
Has no real or apparent conflicts of interest to report.
Dave Hill, MITRE
Has no real or apparent conflicts of interest to report.
3
Disclaimer
This presentation was current at the time it was published or uploaded
onto the web. Medicare policy changes frequently so links to the source
documents have been provided within the document for your reference.
This presentation was prepared as a service to the public and is not
intended to grant rights or impose obligations. This presentation may
contain references or links to statutes, regulations, or other policy
materials. The information provided is only intended to be a general
summary. It is not intended to take the place of either the written law or
regulations. We encourage readers to review the specific statutes,
regulations, and other interpretive materials for a full and accurate
statement of their contents.
4
Agenda
The patient story and value of post-acute care interoperable
exchange across the continuum
IMPACT Act and CMS Data Element Library
Advancing interoperability by aligning assessment content with
industry standards and mapping content to vocabularies,
terminologies and code sets
Health Data Exchange through FHIR
Conclusion and Q&A
5
Objectives
Describe the CMS approach for development and implementation of
the CMS Data Element Library.
Describe how various users can utilize the CMS DEL functionality
including search and reports.
Define the goals of standardized CMS assessment content mapped to
HIT vocabularies and exchange standards.
Discuss the strategies and use cases for how assessment content can
be re-used to support discharge planning, quality improvement, and
reduce burden through interoperable health information exchange.
Explore how the emerging FHIR standards can be used to enable
exchange among providers and with patients and their care givers.
6
Acronyms in this Presentation
CMS Centers for Medicare & Medicaid Services
CCD Continuity of Care Document
C-CDA HL7 Consolidated Clinical Document Architecture
CCDS Common Clinical Data Set
DCPAC Division of Chronic and Post-Acute Care
DEL Data Element Library
FHIR Fast Healthcare Interoperability Resources
HHA Home Health Agency
HIS Hospice Item Set
HIT Health Information Technology
HL7 Health Level 7
IMPACT Improving Medicare Post-Acute Care Transformation Act
IRF Inpatient Rehabilitation Facility
IRF-PAI Inpatient Rehabilitation Facility Patient Assessment
Instrument
7
Acronyms in this Presentation (Cont.)
ISA ONC Interoperability Standards Advisory
LCDS Long-Term Care Hospital (LTCH) Continuity Assessment
Record and Evaluation (CARE) Data Set
LOINC Logical Observation Identifiers Names and Codes
LTCH Long-Term Care Hospital
MDS Minimum Data Set
OASIS Outcome and Assessment Information Set
ONC Office of the National Coordinator for Health IT
PAC Post-Acute Care
RELMA -- Regenstrief LOINC Mapping Assistant
SNF Skilled Nursing Facility
SNOMED-CT Systematized Nomenclature of Medicine - Clinical Terms
SPADEs Standardized Patient Assessment Data Elements
USCDI -- U.S. Core Data for Interoperability
VSAC Value Set Authority Center
8
The patient story and value of post-acute
care interoperable exchange across the
continuum
9
The Patient Story
Ms. Smith
Psychiatric Hospital
Hospital A
Skilled Nursing Facility
Inst. Pharmacy
Hospital B
Home Health
Primary Care
Provider
MDS OASIS
Dialysis Center
FASI
Ms. Smith Daughter
EMS
Home and Community
Based Services
10
Why is Post-Acute Care
Important?
PAC Setting
Long
-
term Care Hospitals (LTCH)
Skilled Nursing Facilities (SNF)
Home Health Agencies (HHA)
Inpatient Rehabilitation Facilities
(IRF)
Hospices
Approximately 33,000 PAC
Providers in the U.S.
Almost 45% of Medicare
hospital discharges are
followed by PAC use
(1)
11
Episodes Requiring PAC Services
after an Acute Hospitalization
No Services
55%
PAC
Services
45%
MEDICARE BENEFICIARIES REQUIRING PAC
SERVICES AFTER AN ACUTE HOSPITALIZATION IN
2014
12
The Most Frequent Sequences of Care
Acute
Hospitalization
HHA
SNF
HHA HHA
SNF HHA
42.9%
18.2%
7.5%
6%
Physicians and specialists also coordinate
on-going care with PAC settings.
Source: http://www.medpac.gov/docs/default-source/contractor-reports/sept2018_pac_sequence_of_care_w_cov_contractor_sec.pdf?sfvrsn=0
13
Volume of Claims by Chronic
Conditions in 2016
Source: 2016 Medicare Claims Data
14
Distribution of Beneficiaries by Number
of Chronic Conditions & Total Medicare
Spending in 2015
Source: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Dashboard/chronic-conditions-state/cc_state_dashboard.html
15
ONC Data Brief: SNF & HHA EHR
Adoption and Interoperability in 2017
EHR
78%*
No
EHR
22%
HHA
EHR
66%
No
EHR
34%
SNF
EHR adoption rates were higher among HHAs compared to SNFs in 2017
HHAs are more likely than SNFs to engage in each domain of interoperability.
41%*
52%*
53%*
36%*
55%*
27%
41% 41%
18%
48%
Find Send Receive Integrate Outside Info
Available
HHA SNF
Source: https://www.healthit.gov/sites/default/files/page/2018-11/Electronic-Health-Record-Adoption-and-Interoperability-among-U.S.-Skilled-Nursing-Facilities-and-Home-Health-Agencies-in-2017.pdf
16
Interoperability Challenges
Lack of business case
Revenue levels (e.g. HITECH), what can they invest in IT?
No financial incentives to cover PACs
Economic motivation for interoperability needed
Lack of standards or consistent use of standards
Use of standards varies across HIEs
Different parts of healthcare address overlapping things differently
Limited understanding of interoperability and its value
Lots of education needed (efficiency gains, improvements in care quality, etc.)
Even with advanced tools, lots of paper still exchanged
Lack of formalized workflows
What needs to be done when data arrives?
Using 10 different ways to discharge a patient
17
Interoperability Challenges (cont. 1)
Frequent changes to payment models diverts resources from
investment in interoperability
Vendors have divert resources to update software
Providers have divert resources to purchase updates
Meeting CMS regulatory requirements diverts resources from
investment in interoperability
Regulation focus takes resources away from health IT
Lack of data transparency
What data is available and from where?
Data exchange between EHR systems is poor
Interoperability across different versions of same EHR and between
different EHRs is problematic
18
Interoperability Challenges (cont. 2)
Staff recruiting and retention in PAC facilities
Decreasing Medicare reimbursements, competing with private industry (e.g.
Amazon), training costs, 30-40% attrition in SNFs
Accessibility is problematic for some patients
Portals, username/password challenging for mentally-challenged
Working physicians are not involved enough in standards development
and software design
EHRs are difficult to use and burden clinicians
Many involved clinical SMEs lack recent experience with patients
Senior housing facilities do not employ any health IT infrastructure
Senior housing facilities consider themselves landlords
19
Interoperability Challenges (cont. 3)
Assisted living facilities have been slow to adopt EHRs
Frailty and complexity of medications tracking/management
Post-acute utilization is high and increasing
Focus on reducing length of stay in hospitals increases post-acute
usage
Internet connectivity for some health facilities is poor
Small and rural providers need representation
Patient matching is difficult, inaccurate, and hard to automate
Algorithms exist, but manual matching is still required
Data provided by ambulatory care are not timely
Data frequently not available to PAC facilities when needed
20
Points of Failure
Poor communication across care providers, including outpatient
Medication discrepancies such as drug omissions during transitions of
care are common
Multiple modes of information transmission are often used
Delays in PAC services can lead to adverse events and preventable
readmissions
Redundant information collection creates inefficiencies and burden
Reliance on patient recall during periods of high stress
Recall of information can be unreliable
Increased patient / family stress
Increased Cost and Provider Burden
Additional costs related to hospital stays from adverse events,
readmissions
Additional administrative costs to locate, reconcile and coordinate
information
Longer length of stays and higher resource utilization
21
Potential Cost Savings related to Points
of Failures
Description
Financial Cost
-faxing or sending information
$107 *
$13,745 #
$3,040
$19,714
$18,174
-Term Care Hospital stay $40,656
* https://www.medscape.com/slideshow/2018-compensation-overview-6009667#2
# L Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General;
November 2010. Report No. OEI-06-09-00090
† MedPAC, A Data Book: Health care spending and the Medicare program, June 2018
22
IMPACT Act and CMS Data Element Library
(DEL)
23
IMPACT Act of 2014
Bi-partisan bill passed on September 18, 2014, and signed into
law October 6, 2014
The Act requires standardized patient assessment data elements
for:
Long-term Care Hospitals (LTCHs)
Skilled Nursing Facilities (SNFs)
Home Health Agencies (HHAs)
Inpatient Rehabilitation Facilities (IRFs)
The Act specifies that data “… be standardized and
interoperable so as to allow for the exchange of such data
among such post-acute care providers and other providers
and the use by such providers of such data that has been so
exchanged, including by using common standards and
definitions in order to provide access to longitudinal
information for such providers to facilitate coordinated care
and improved Medicare beneficiary outcomes…”.
Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014
24
Data Element Interoperability
IMPACT Act requires that post-acute care assessment data elements
be interoperable to:
allow for the exchange of data among PAC providers and other
providers and the use by such providers of such data that has been
exchanged, including by using common standards and definitions, in order
to provide access to longitudinal information for such providers to
facilitate coordinated care and improved Medicare beneficiary
outcomes.”
Interoperable data elements facilitate improvements to reduce overall
provider burden by allowing the use and exchange of healthcare data
Supports provider exchange of electronic health information to
facilitate care coordination and person-centered care
Supports real-time, data driven, clinical decision making
25
IMPACT Act Requirements
Data Must be Interoperable
Quality Measures
Functional Status
Skin Integrity
Medication Reconciliation
Incidence of Major Falls
Transfer of Health
Information
Resource Use and Other
Measures
Medicare Spending per
Beneficiary
Discharge to Community
Potentially Preventable
Hospital Readmissions
Standardized Data
Submission
Admission and Discharge
Functional status
Cognitive function and
mental status
Special services,
treatments, and
interventions
Medical conditions and
co-morbidities
Impairments
Other categories required
by the Secretary
26
Post-Acute Care Assessments
OASIS C2
CMS PAC
Assessments
LTCH Continuity
Assessment
Record
& Evaluation (CARE)
Data Set (LCDS)
Resident
Assessment
Instrument
(RAI)
Minimum Data Set
(MDS)
Outcome and
Assessment
Information Set
(OASIS)
IRF Patient
Assessment
Instrument (IRFPAI)
Hospice Item Set
(HIS)
27
PAC Assessment Content
Administrative Content
Patient Name
Date of Birth
Race/Ethnicity
Marital status
Admission/Discharge dates
Admit from/Discharged to locations
Reason for admission
Provider NPI, CCN, Medicaid Provider #
Standardized Patient Assessment
Data Elements (SPADEs) across
instruments
Function (e.g., self care and mobility)
Cognitive function (e.g., express &
understand ideas; mental status, such as
depression and dementia)
Special services, treatments &
interventions (e.g., need for ventilator,
dialysis, chemotherapy, and total
parenteral nutrition)
Medical conditions and co-morbidities
(e.g., diabetes, heart failure, and pressure
ulcers)
Impairments (e.g., incontinence; impaired
ability to hear, see, or swallow)
Other categories
Clinical Content
Diagnosis/medical conditions
Mental/Cognitive Status (memory,
orientation, consciousness, delirium,
mood, behavior)
Communication (express needs,
understanding verbal/non-verbal content,
hearing and vision)
Functional Status (Self-care/ADLs,
Mobility, Use of assistive devices)
Bladder and Bowel continence
Falls
Pressure ulcers and other skin conditions
Surgery
Nutritional and swallowing status
Medication information
Special treatments, procedures &
programs
Height and Weight
Patient preferences and goals of
treatment
Pain
Vaccinations
Therapy- PT, OT, SLT
Living arrangements/support availability
Care planning
28
SPADES: Standardized Assessment:
Many Uses
Payment
Data Elements: Question and Response
QI
Care Planning/
Decision Support
Quality
Reporting
Care
Transitions
29
The Data Element Library (DEL)
The DEL is a centralized resource for CMS assessment data
elements (e.g. questions and response options), and their
related mappings to nationally accepted health IT standards
DEL Contents
Assessment and version (e.g., MDS
3.0 v. 1.16)
Item label (e.g.- GG0170)
Item status (Published, Active,
Inactive)
Copyright information (if applicable)
CMS usage (Payment, Quality
Measure, Survey and Certification,
etc.)
Identification of skip pattern triggers
and lookback periods
Health IT standards (e.g., LOINC,
SNOMED)
Visit the DEL here: https://del.cms.gov
PAC Setting CMS Assessment
Long
-
term Care Hospitals (LTCHs)
LTCH Continuity Assessment
Record & Evaluation (CARE) Data
Set (LCDS)
Skilled Nursing Facilities (SNFs)
Resident Assessment Instrument
(RAI) Minimum Data Set (MDS)
Home Health Agencies (HHAs)
Outcome and Assessment
Information Set (OASIS)
Inpatient Rehabilitation Facilities
(IRFs)
IRF patient assessment instrument
(IRF
-PAI)
Hospices
Hospice Item Set
30
DEL
Homepage
Overview
Announcements
Listserv
Visit the DEL here:
https://del.cms.gov
31
Search Categories
32
Search Results List
33
Detailed Data Element Information
34
OASIS D Health IT Codes
35
Trainings/FAQs
36
Alignment and Interoperability: Advancing
interoperability by aligning assessment
content with industry standards and
mapping content to vocabularies,
terminologies and code sets
37
Guiding Principle: Data Needs to
Follow the Person
Support data availability in real-time. Electronic information is exchanged
and used by health IT systems without special effort on the part of the
user.
38
Making PAC Assessment Data Elements
Standardized/Aligned and Interoperable
Relevant interoperable
assessment data (such
as functional status,
cognitive status, etc.)
can be used to populate
documents
39
CMS Data Element Library HIT
Workgroup Focus
Vision for
Interoperable
Assessment
Content
Aligning with
National
Standards
Mapping to
Relevant
Vocabulary &
Terminology
Standards
Use of
Interoperable
Assessment
Content by
Implementers
Opportunities for
Burden Reduction
Use Cases for
Interoperable
Assessment
Content
40
Vision for Interoperable Assessment
Content
Strategy: Leverage standardized data that is
collected on almost all PAC patients to advance
interoperability, reduce burden, and improve patient
care.
Models:
Identify single code to represent the
assessment question and response and re-
use data in relevant exchange documents
(current focus)
Identify a value set of codes that could be
used to support completion of an assessment
item (future)
41
Opportunities for Burden Reduction
and Improved Communication
Real-time data availability improves patient care
Machine processable data reduces provider burden:
Eliminates duplicative data entry
Minimizes searching medical record for relevant content
Experiences of Early Adopters - Faster Data Entry
Valuable to have common data standards across provider
types
Data from exchange documents (e.g. CCD) populates the
patient record
42
Use Cases for Interoperable
Assessment Content
Care coordination between multiple
providers / proxy / family members
Appointments, readmissions,
sharing care plan, chart sharing,
transportation
Transitions of care referrals
Intake, info queries, transition out,
follow-up activity coordination
Medication reconciliation
Clinical decision support
Admission / Discharge information
notifications
Helps all parties to track patient
status
Population Health Management
Administration
Quality management, at risk
dollars, who is high risk and
why
Changing relationship between
patient and caregivers
Connective devices, patient
engagement, monitoring,
telehealth
Getting providers engaged
Quality compared to peers,
financial metrics, cost of care
Advanced directives
Sharing and notifications
43
Aligning with National Standards
ONC Interoperability Standards Advisory
DEL health IT standards align with
national policy
LOINC and SNOMED-CT for assessment content
Analyzed Common Clinical Data Set/U.S. Core Data for
Interoperability (USCDI)
Identified opportunities for alignment of assessment content to
USCDI
Provided comments on future candidate data types important to
support PAC for USCDI expansion
2019 ONC Interoperability Standards Advisory: https://www.healthit.gov/isa/sites/isa/files/inline-
files/2019ISAReferenceEdition.pdf
ONC Common Clinical Data Set: https://www.healthit.gov/public-course/interoperability-basics-
training/lsn1069/010110---a.htm
Draft USCDI: https://www.healthit.gov/sites/default/files/draft-uscdi.pdf
44
Mapping to Relevant Vocabulary &
Terminology Standards
Selected codes aligned with national policy and
utilized in exchange standards (e.g. C-CDA templates)
Mapped assessment content to LOINC and SNOMED
LOINC codes represent the question and answer
SNOMED codes represent the answer meaning
LOINC codes are available for PAC assessments on the DEL
GG0100 as Shown on IRF-PAI
45
Use of Interoperable Assessment
Content by Implementers
Best practices for data element design to support
interoperability
Ensure health IT content vocabularies Use in HIE standards
Leverage DEL’s content with other industry tools such as:
Value Set Authority Center (VSAC)
Regenstrief LOINC Mapping Assistant (RELMA)
Convene Advisory Group (industry and HHS)
Input on future direction for DEL and health IT priorities
Identify priority use cases that leverage existing
standards and address gaps. Tailor implementation
guides and coordinate testing.
46
Industry Expert Roundtable on CMS
Data Element Library
Provided feedback
on the CMS Data
Element Library:
Inform healthcare
policies
Advance
interoperability
Support transfer
of care,
coordination of
care, quality
measurement,
and research
Suggested clarifying scope of DEL and how it
should be used by stakeholders; Ideas for future
development.
Identified priority use cases for transfer
summary and care planning; Suggested ways
the DEL to support outreach & testing.
Become a resource to connect industry standards
align with other tools, identify/point to relevant
standards, fill gaps.
47
Health Data Exchange through FHIR
48
We’re Building the Future with FHIR
1) Participate with the right HL7 Working Groups
2) Create sustainable PAC Interoperability Working Group
3) Identify tightly-scoped use case to implement for a connect-a-
thon
4) Develop FHIR Implementation Guides for use case data
models
5) Review and harmonize FHIR Implementation Guides with
key stakeholders
6) Host connect-a-thon to test FHIR Implementation Guides
7) Build industry consensus around FHIR Implementation
Guides
8) Identify next agile part of use case to implement, and repeat
steps 4 through 8.
49
Outpatient EMS Inpatient
Home Health
50
EMS Inpatient SNF
51
Proposed Timeline for FHIR Work
(Publish Dec 2019)
1 October 2018 31 March 2020
Nov 2018 Dec 2018 Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 Jan 2020 Feb 2020 Mar 2020
LANDSCAPE ANALYSIS
Oct 2019
NEW FISCAL YEAR
Sep 2019
2019 WGM AND
CONNECTATHON
IN ATLANTA
28 Nov, 2018
TAG
GENERATE FHIR PROFILES
Mar 2019
PROJECT SCOPE STATEMENT
30 Jun, 2019
NOTICE OF INTENT TO
BALLOT - DEADLINE
Jul 2019
BALLOT CONTENT
Nov 2019
RECONCILIATION
Dec 2019
PUBLISH FHIR
IMPLEMENTATION
GUIDE
52
Proposed Timeline for FHIR Work
(Publish Mar 2020)
1 October 2018 31 March 2020
Nov 2018 Dec 2018 Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 Jan 2020 Feb 2020 Mar 2020
LANDSCAPE ANALYSIS
27 Oct, 2019
NOTICE OF INTENT TO
BALLOT - DEADLINE
Oct 2019
NEW FISCAL YEAR
Nov 2019
BALLOT CONTENT
Jan 2020
JANUARY 2020
CONNECTATHON AND WGM
Sep 2019
2019 WGM AND
CONNECTATHON
IN ATLANTA
Mar 2020
RECONCILIATION
Mar 2020
PUBLISH FHIR
IMPLEMENTATION
GUIDE
28 Nov, 2018
TAG
GENERATE FHIR PROFILES
Mar 2019
PROJECT SCOPE STATEMENT
53
Call to Action: How to Participate
Health IT developers
Build on existing health
IT systems
Try out new
projects/systems
PAC providers
Analyze how and where
assessment data fits in
clinical workflow
Provide feedback on
development priorities
Ways to contribute:
Subject matter expertise
Scalability of implementing
the eventual solution
Assist in the delivery of key
deliverables and
project artifacts
Development of testing
tools, testing
implementations, etc.
To participate in PAC Interoperability workgroup and FHIR
connect-a-thon contact: Dave Hill, dwhill@mitre.org
54
Wrap Up and Q&A
55
Resources
For more information on the IMPACT Act, visit the IMPACT Act
webpage
For more information on Post-Acute Care Quality Reporting
Programs, visit:
Home Health Agencies
Hospice Agencies
Inpatient Rehab Facilities
Long-term Care Hospitals
Skilled Nursing Facilities
For DEL updates, sign up for the listserv here
For DEL feedback or questions, contact: DELHelp@cms.hhs.gov
56
Thank You
Beth Connor, CMS
Beth.Connor@cms.hhs.gov
Elizabeth Palena Hall, ONC
Elizabeth.PalenaHall@hhs.gov
Michelle Dougherty, RTI International
MDougherty@rti.org
@mvldougherty
Dave Hill, MITRE
Dwhill@mitre.org
CMS
Contractors
supporting the
DEL:
NIC/Telligen
RTI International
MITRE
Remember to complete the online session evaluation